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The Balint Society

Journal of the Balint Society

Vol. 36, 2008

Contents

Editor: John Salinsky
Assistant editor: Mary Salinsky

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Editorial: How does the Balint group develop? A Kleinian perspective.

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In this editorial we return to the question addressed last year: what do doctors gain from attending a Balint group? What are they looking for when they join? What do they need to feel happier in their work? How do they change? As group leaders, we may hope for an increased insight into the feelings of their patients and themselves. This might show it self in greater evidence of empathy, a willingness to see things from the patient's point of view. Will there be a limited though considerable change in personality? How could we tell? One way in which the leaders can observe how their group members change is to look at the kind of patients they present, the kind of stories that they tell and the way those stories are received.

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Early in the life of a group of doctors new to Balint, the patient is often seen as an enemy. He is outside the door of the inner surgery, trying to get in. The doctor wishes he would go away and is asking the group for help in getting rid of him.

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These patients make the doctor feel uncomfortable in a variety of ingenious ways.

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They demand medication that is inappropriate (antibiotics) or not allowed (benzodiazepines). In spite of good advice, they refuse to change their life style. They may smell of alcohol. They demand absurd referrals and ask for unnecessary home visits. They may make the young inexperienced doctor feel humiliated and inadequate by asking to see someone more senior. Or they may appear in her surgery too often, showing worrying signs of an unhealthy 'dependency'.

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do all these nightmare patients come from? Does the Balint group exist to help get rid of them? They seem so obnoxious that no one can possibly empathise with them although leaders may make heroic efforts. It appears that we here only to listen, share the pain and bandage the wounds before the doctor returns to the front line, feeling at least that he has been cared for. The patient remains angrily outside the door and we all hope he will eventually slink away.

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But as the group continues, a new kind of patient appears. Or perhaps the same patient seen in a different light. We start to hear stories of patients the doctor actually likes, although she may be surprised when this is pointed out to her. These patients also cause the doctor discomfort but now they make her feel responsible. They are seen as needy rather than demanding. When they knock at the door they are invited inside and allowed to warm themselves at the fire. Examples might be a woman supporting a family in difficult circumstances; an old man living alone and rejecting attempts to move him into a care home; a young person who is miserable and has lost the thread of his life.

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We are reminded of Melanie Klein's model of infant development in which the infant's inner world of fantasy moves from the 'paranoid-schizoid' position to the 'depressive position'. In the earlier phase, everything good is kept within the self and everything felt to be bad is expelled and projected into the person of the 'bad' mother. After a while, Mrs Klein tells us, the little one begins to realise that the mother who is horrid and spiteful is also the loving mother who provides milk and care. This leads to remorse about the way she has been treated in fantasy and an urge to restore the damaged internal mother to health. We may not find this convincing as a literal account of infant development but it is easy to observe the alternation between these two modes of thought in our own adult minds and in our relationships with others.

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seems to us that in the early infant stage of the Balint group, the patients we hear described represent everything the doctor hates and fears. They need to be separated out and expelled from her mind to the space outside the inner surgery. The group is asked to listen and sympathise and endorse the expulsion. This is the paranoid schizoid group. A few months later (maybe a year) there are signs of change. Now we hear about patients who are themselves in danger and have been ill treated by their families or perhaps just by life. In telling these stories the doctor seeks relief from her guilt at having failed to protect them adequately and encouragement in finding new ways of helping them. This is often achieved by understanding what the patient really needs from the doctor. The group has reached 'the depressive position': but this does not mean they are depressed.

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So let us not be dismayed if, in the first few months, the group seems paranoid and the patients hateful. With a little patience we shall see splitting and expulsion giving way to concern and responsibility and a little love. Reference
    Klein, M. (1952) Some theoretical considerations regarding the emotional life of the infant. In Envy and Gratitude and other works (1975) Hogarth Press and the Institute of Psychoanalysis: London.